RESUMEN
BACKGROUND: Titin (TTN)-related dilated cardiomyopathy (DCM) has a higher likelihood of left ventricular reverse remodelling compared with other genetic etiologies. No data regarding the evolution of right ventricular dysfunction (RVD) according to genetic background are available. METHODS: Consecutive 104 DCM patients with confirmed pathogenic genetic variants (51 TTN-related DCM; 53 other genetic DCM) and a control group of 139 patients with negative genetic testing and available follow-up data at 12-24 months were analysed. RVD was defined as a right ventricular fractional area change (RVFAC) < 35%. The main study end point was the comparison of the evolution of RVD and the change of RVFAC throughout the follow-up according to etiology. A composite of all-cause mortality and heart transplantation was included as outcome measure. RESULTS: At enrollment, RVD was present in 29.1% of genetically positive DCM without differences between genetic cohorts. At 14 months follow-up, 5.9% of TTN-related DCM patients vs 35.8% of other genetic DCM patients had residual RVD after treatment (P < 0.001). Accordingly, RVFAC significantly improved in the TTN-related DCM cohort and remained stably impaired in other genetic DCM patients. However, the evolution of RVD was similar between TTN-related DCM and patients without a genetic mutation. After adjusting for RVD at follow-up, no differences in the outcome measure were seen in the study cohorts. CONCLUSIONS: The evolution of RVD in DCM is heterogeneous in different genetic backgrounds. TTN-related DCM is associated with a higher chance of RVD recovery compared with other genetic etiologies.
Asunto(s)
Cardiomiopatía Dilatada/genética , Disfunción Ventricular Derecha/epidemiología , Función Ventricular Derecha/fisiología , Remodelación Ventricular/fisiología , Adulto , Cardiomiopatía Dilatada/complicaciones , Cardiomiopatía Dilatada/fisiopatología , Conectina/genética , Conectina/metabolismo , Femenino , Estudios de Seguimiento , Antecedentes Genéticos , Humanos , Masculino , Persona de Mediana Edad , Mutación , Fenotipo , Prevalencia , Estudios Retrospectivos , Disfunción Ventricular Derecha/etiología , Disfunción Ventricular Derecha/fisiopatologíaRESUMEN
The case highlights the value of contrast echocardiography in raising clinical suspicion of malignancy, allowing a diagnostic work-up and the treatment of the primitive heart tumors.
RESUMEN
BACKGROUND: The early diagnosis of genetically determined dilated cardiomyopathy (DCM) could improve the prognosis in mutation carriers. Left ventricular global longitudinal strain (LV GLS) and peak left atrial longitudinal strain (PALS) are promising techniques for the detection of subtle systolic and diastolic dysfunction. We sought to evaluate the prevalence of subtle systolic and diastolic dysfunction by LV GLS and PALS in a cohort of genotype-positive phenotype-negative (GPFN) DCM relatives. METHODS AND RESULTS: In this retrospective study, we analyzed echocardiograms of forty-one GPFN relatives of DCM patients. They were compared with age and sex matched healthy individuals (control group). Reduced LV GLS and PALS were defined as >18% and <23.1%, respectively. GPFN relatives (37 ± 14 years, 48.8% male) and controls were similar according to standard echocardiographic measurements. Conversely, LV GLS was -18.8 ± 2.7% in the GPFN group vs. -24.0 ± 1.8% in the control group (p < 0.001). Twenty subjects (48.8%) in the GPFN group and no subjects in the control group had a reduced LV GLS. PALS was 29.2 ± 6.7% in the GPFN group vs. 40.8 ± 8.5% in the control group (p < 0.001). Seven subjects (18.4%) in the GPFN group and one (2%) in the control group had a reduced PALS. A cohort of 17 genotype-negative phenotype-negative relatives showed higher values of LV GLS compared to GPFN. CONCLUSIONS: Despite standard echocardiographic parameters are within the normal range, LV GLS and PALS are lower in GPFN relatives of DCM patients when compared to healthy individuals, suggesting a consistent proportion of subtle systolic and diastolic dysfunction in this population.
Asunto(s)
Cardiomiopatía Dilatada , Disfunción Ventricular Izquierda , Cardiomiopatía Dilatada/diagnóstico por imagen , Cardiomiopatía Dilatada/epidemiología , Cardiomiopatía Dilatada/genética , Femenino , Genotipo , Humanos , Masculino , Fenotipo , Prevalencia , Estudios Retrospectivos , Volumen Sistólico , Disfunción Ventricular Izquierda/diagnóstico por imagen , Disfunción Ventricular Izquierda/epidemiología , Disfunción Ventricular Izquierda/genética , Función Ventricular IzquierdaRESUMEN
Echocardiography is a reliable and reproducible method to assess non-invasively cardiac function in clinical and experimental research. Significant progress in the development of echocardiographic equipment and transducers has led to the successful translation of this methodology from humans to rodents, allowing for the scoring of disease severity and progression, testing of new drugs, and monitoring cardiac function in genetically modified or pharmacologically treated animals. However, as yet, there is no standardization in the procedure to acquire echocardiographic measurements in small animals. This position paper focuses on the appropriate acquisition and analysis of echocardiographic parameters in adult mice and rats, and provides reference values, representative images, and videos for the accurate and reproducible quantification of left ventricular function in healthy and pathological conditions.
Asunto(s)
Investigación Biomédica/normas , Enfermedades Cardiovasculares/diagnóstico por imagen , Ecocardiografía/normas , Función Ventricular Izquierda , Animales , Enfermedades Cardiovasculares/fisiopatología , Consenso , Diástole , Modelos Animales de Enfermedad , Ratones , Ratas , SístoleRESUMEN
Cardiomyopathies are primary myocardial disorders, genetically determined, with clinical onset between the third and the fifth decade of life. They represent the main causes of sudden cardiac death and heart failure in the youth. The more common myocardial diseases in clinical practice are dilated cardiomyopathy, arrhythmogenic cardiomyopathy and hypertrophic cardiomyopathy. Next generation sequencing techniques, recently available for genetics researches, together with the diffusion of advanced imaging techniques, permitted in the last years a deeper knowledge of these pathologies. Nevertheless, diagnosis, etiology and several aspects of patients' clinical management remain complex and controversial. This review paper aims to propose some operative flow-charts, derived from scientific evidences and the internal protocol of the Cardiothoracovascular Department of Trieste Hospital, Italian referral Center for cardiomyopathies and heart failure, with more than 30 years of experience in diagnosis and management of patients who suffer from primary myocardial disorders.
Asunto(s)
Cardiomiopatías , Adolescente , Displasia Ventricular Derecha Arritmogénica/diagnóstico , Displasia Ventricular Derecha Arritmogénica/genética , Displasia Ventricular Derecha Arritmogénica/terapia , Cardiomiopatías/diagnóstico , Cardiomiopatías/terapia , Cardiomiopatía Dilatada , Cardiomiopatía Hipertrófica/diagnóstico , Cardiomiopatía Hipertrófica/genética , Cardiomiopatía Hipertrófica/terapia , Humanos , ItaliaRESUMEN
Arrhythmogenic right ventricular cardiomyopathy is a myocardial disease generally caused by desmosomal mutations and characterized by progressive replacement of cardiomyocites with fibro-adipose tissue. In the classic form of the disease right ventricle is predominantly affected. However, biventricular and left-dominant variants have been recently recognized, leading to the new nosological definition of arrhythmogenic cardiomyopathy. The condition affects mostly young adults and athletes and is clinically characterized by ventricular arrhythmias, heart failure and sudden cardiac death. The diagnosis is based on clinical-instrumental criteria, including family history, morpho-functional and electrocardiographic abnormalities, ventricular arrhythmias and genetic defects (Task Force Criteria, 2010). The main goal in the management of patients is the prevention of sudden cardiac death, where implantable cardioverter-defibrillator is the only effective therapeutic strategy. Many arrhythmic risk factors have been described. Recently, an on-line calculator has been proposed, but it needs further validation.
RESUMEN
OBJECTIVE: The index of maximal systolic acceleration ([AImax]: maximal systolic acceleration of the Doppler waveform divided by peak systolic velocity) shows diagnostic accuracy in screening of renal artery stenosis. This study aimed to determine whether an upstream factor of resistance, such as aortic valve stenosis (AVS), can affect Doppler parameters detected in the peripheral arteries. METHODS: In this prospective study, we measured the AImax in non-stenotic renal interlobar arteries of 62 patients with AVS. Patients were divided into three groups on the basis of severity of valvulopathy as follows: mild-to-moderate AVS (M-AVS; n = 24), intermediate AVS (I-AVS; n = 15), and severe AVS (S-AVS; n = 23) based on Nishimura's criteria. RESULTS: The AImax in the renal parenchymal arteries was significantly lower in the S-AVS group (8.9 ± 3.6 s-1) than in the M-AVS (15.3 ± 3.8 s-1) and I-AVS groups (16.7 ± 5.2 s-1). The AImax was positively correlated with the aortic valve area and inversely correlated with the tranvalvular aortic pressure gradient. After aortic valve replacement, the AImax significantly increased from 10.7 ± 4.0 s-1 at baseline to 19.3 ± 4.4 s-1. CONCLUSIONS: Proximal resistance can lead to diagnostic bias of Doppler parameters that are applied in the diagnosis of peripheral vasculopathies, particularly in renal artery stenosis.
Asunto(s)
Estenosis de la Válvula Aórtica , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/cirugía , Velocidad del Flujo Sanguíneo , Hemodinámica , Humanos , Estudios Prospectivos , Circulación RenalRESUMEN
BACKGROUND: Cardiac masses (CM) encompass a broad set of lesions that can be either neoplastic or non-neoplastic. A stepwise diagnostic strategy through multimodality imaging evaluation is the cornerstone for the appropriate approach. CASE SUMMARY: We report the case of an 83-year-old man presenting at the emergency department for acute heart failure showing bilateral atrial masses without unequivocal aetiological aspects at several imaging techniques, emphasizing the critical aspects in the differential diagnosis. DISCUSSION: In the complex field of CM, a proper differential diagnosis is very important in order to start the appropriate treatment; however, sometimes it could be challenging despite a multimodality imaging approach, therefore still requiring histologic examination.
RESUMEN
AIM: Contemporary survival trends in dilated cardiomyopathy (DCM) are largely unknown. The aim of this study is to investigate clinical descriptors, survival trends and the prognostic impact of aetiological characterization in DCM patients. METHODS AND RESULTS: Dilated cardiomyopathy patients were consecutively enrolled and divided into four groups according to the period of enrolment (1978-1984; 1985-1994; 1995-2004; and 2005-2015). A subset of patients with DCM of specific aetiology, enrolled from 2005 to 2015, was also analysed. Over a mean follow-up of 12 ± 8 years, 1284 DCM patients (52 in the 1978-1984 group, 326 in the 1985-1994 group, 379 in the 1995-2004 group, and 527 in the 2005-2015 group) were evaluated. Despite older age (mean age 51 ± 15, 43 ± 15, 45 ± 14, and 52 ± 15 years for the 1978-1984, 1985-1994, 1995-2004, and 2005-2015 groups, respectively; P < 0.001), most of the baseline clinical characteristics improved in the 2005-2015 group, suggesting a less advanced disease stage at diagnosis. Similarly, at competing risk analysis, the annual incidence of all outcome parameters progressively decreased over time (global P < 0.001). At multivariable analysis, the last period of enrolment emerged as independently associated with a reduction in all-cause mortality/heart transplantation (HTx)/ventricular assist device (VAD) implantation (1.46 events/100 patients/year), cardiovascular death/HTx/VAD implantation (0.82 events/100 patients/year) and sudden cardiac death (0.15 events/100 patients/year). Lastly, in 287 patients with DCM of specific aetiology, patients with environmental, toxic, or removable factors appeared to have different phenotypes and prognosis compared to those with genetic, post-myocarditis, or idiopathic DCM (P < 0.001). CONCLUSIONS: Contemporary survival trends in DCM significantly improved, mainly due to a reduction of cardiovascular events. Appropriate aetiological characterization might help in prognostication of DCM patients.
Asunto(s)
Cardiomiopatía Dilatada , Insuficiencia Cardíaca , Adulto , Anciano , Cardiomiopatía Dilatada/epidemiología , Trasplante de Corazón , Humanos , Persona de Mediana Edad , Pronóstico , Factores de RiesgoRESUMEN
The echocardiographic estimation of right atrial pressure (RAP) is based on the size and inspiratory collapse of the inferior vena cava (IVC). However, this method has proven to have limits of reliability. The aim of this study is to assess feasibility and accuracy of a new semi-automated approach to estimate RAP. Standard acquired echocardiographic images were processed with a semi-automated technique. Indexes related to the collapsibility of the vessel during inspiration (Caval Index, CI) and new indexes of pulsatility, obtained considering only the stimulation due to either respiration (Respiratory Caval Index, RCI) or heartbeats (Cardiac Caval Index, CCI) were derived. Binary Tree Models (BTM) were then developed to estimate either 3 or 5 RAP classes (BTM3 and BTM5) using indexes estimated by the semi-automated technique. These BTMs were compared with two standard estimation (SE) echocardiographic methods, indicated as A and B, distinguishing among 3 and 5 RAP classes, respectively. Direct RAP measurements obtained during a right heart catheterization (RHC) were used as reference. 62 consecutive 'all-comers' patients that had a RHC were enrolled; 13 patients were excluded for technical reasons. Therefore 49 patients were included in this study (mean age 62.2 ± 15.2 years, 75.5% pulmonary hypertension, 34.7% severe left ventricular dysfunction and 51% right ventricular dysfunction). The SE methods showed poor accuracy for RAP estimation (method A: misclassification error, ME = 51%, R2 = 0.22; method B: ME = 69%, R2 = 0.26). Instead, the new semi-automated methods BTM3 and BTM5 have higher accuracy (ME = 14%, R2 = 0.47 and ME = 22%, R2 = 0.61, respectively). In conclusion, a multi-parametric approach using IVC indexes extracted by the semi-automated approach is a promising tool for a more accurate estimation of RAP.
Asunto(s)
Algoritmos , Función del Atrio Derecho , Presión Atrial , Enfermedades Cardiovasculares/diagnóstico por imagen , Ecocardiografía , Interpretación de Imagen Asistida por Computador , Vena Cava Inferior/diagnóstico por imagen , Anciano , Cateterismo Cardíaco , Enfermedades Cardiovasculares/fisiopatología , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Valor Predictivo de las Pruebas , Estudios Prospectivos , Reproducibilidad de los Resultados , Vena Cava Inferior/fisiopatologíaRESUMEN
The complexity of cardiovascular diseases has led to an extensive use of technological instruments and the development of multimodality imaging. This extensive use of different cardiovascular imaging tests in the same patient has increased costs and waiting times.The concept of appropriateness has changed over time. Appropriateness criteria address the need for specific cardiovascular imaging tests in well-defined clinical scenarios, and define the kind of cardiovascular imaging that is appropriated for each clinical scenario in different stages of the disease. The concept of appropriateness criteria has replaced the old idea of appropriate use criteria and reflects the increasing effort of the international Scientific Societies to create and review in a critical way the management of diagnostic tests used by clinicians.The aim of this Italian consensus document is to address the use of multimodality imaging in the diagnosis and management of the major cardiovascular clinical scenarios, taking into consideration not only the international guidelines and scientific documents already published, but also the reality of Italian laws as well as the various professional profiles involved in patient management and availability of technological diagnostic instruments.
Asunto(s)
Enfermedades Cardiovasculares/diagnóstico por imagen , Consenso , Técnicas de Diagnóstico Cardiovascular/normas , Imagen Multimodal/normas , Servicio de Urgencia en Hospital , Femenino , Humanos , Italia , EmbarazoRESUMEN
PURPOSE: Patients with symptomatic heart failure (HF), reduced left ventricular ejection fraction (LVEF), and high-grade functional mitral regurgitation (MR) may benefit from percutaneous edge-to-edge mitral valve repair (PMVR). However, patient selection still remains a central issue. We sought to investigate the potential role of the global longitudinal strain- (GLS-) based left ventricular contractile reserve (LVCR) at dobutamine stress echocardiography (DSE) in this setting. METHODS: Thirty-three stable HF patients (MR grade ≥ 3+; median LVEF, 29%; median GLS, -8.3%) who were candidates for PMVR were prospectively enrolled. All patients underwent DSE to assess LVCR (LVEF increase ≥ 5%; GLS increase ≥ 2%; stroke volume [SV] increase ≥ 20% of the measured SV value). RESULTS: After DSE, a positive LVCRLVEF was detected in 21 patients (64%), positive LVCRGLS in 12 patients (36%), and positive LVCRSV in 14 patients (42%). LVCRGLS was associated with better symptom relief, MR improvement, and LV reverse remodeling in a short-term follow-up. A significant improvement of GLS during DSE (hazard ratio [HR], 0.549; 95% CI, 0.395-0.765; P < .001), along with history of HF hospitalization (HR, 1.48; 95% CI, 1.119-1.967; P = .006) and beta-blocker therapy (HR, 0.146; 95% CI, 0.046-0.462; P = .001), were independently associated with risk of death/heart transplantation/HF-related hospitalizations. CONCLUSIONS: LVCR, assessed by speckle-tracking DSE, is associated with better results after PMVR in the setting of advanced HF. Improvement of longitudinal function emerged, beyond the ejection fraction, as an independent predictor of outcomes and could improve the selection of best candidates for the percutaneous correction of functional MR.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Ventrículos Cardíacos/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/fisiopatología , Contracción Miocárdica/fisiología , Selección de Paciente , Volumen Sistólico/fisiología , Función Ventricular Izquierda/fisiología , Anciano , Ecocardiografía de Estrés , Femenino , Ventrículos Cardíacos/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/diagnóstico , Insuficiencia de la Válvula Mitral/cirugía , Curva ROC , Estudios RetrospectivosRESUMEN
Background Limited data are available on mid-range ejection fraction (mrEF) patients with dilated cardiomyopathy. We sought to define the characteristics, evolution, and long-term prognosis of dilated cardiomyopathy patients with mrEF at diagnosis. Methods and Results We analyzed all dilated cardiomyopathy patients consecutively evaluated in the Trieste Heart Muscle Disease Registry from 1988 to 2013. mrEF and reduced ejection fraction (rEF) were defined as baseline left ventricular (LV) ejection fraction values between 40% and 49% and <40%, respectively. All-cause mortality or heart transplantation, sudden cardiac death, or major ventricular arrhythmias were considered as outcome measures. Worsening LV ejection fraction (reduction to <40%) during follow-up was also considered to identify possible predictors of adverse remodeling. Among 812 enrolled patients, 175 (22%) presented with mrEF at presentation. At baseline, as compared with the rEF group, mrEF patients had lower rates of moderate-severe mitral regurgitation and restrictive LV filling pattern. During a median follow-up period of 120 (60-204) months, the mrEF group presented a lower rate of death/heart transplantation (9% versus 36%, P<0.001) and sudden cardiac death or major ventricular arrhythmias (4.5% versus 15%, P<0.001) than rEF patients. Moreover, 29 out of 175 mrEF patients (17%) evolved to rEF. Restrictive LV filling pattern emerged as the strongest predictor of rEF development following multivariable analysis. Conclusions mrEF identified a consistent subgroup of dilated cardiomyopathy patients diagnosed in an earlier stage with subsequent apparent better long-term evolution. However, 17% of these patients evolved into rEF despite the use of medical therapy. A baseline restrictive LV filling pattern was independently associated with subsequent evolution to rEF.
Asunto(s)
Cardiomiopatía Dilatada/fisiopatología , Volumen Sistólico , Función Ventricular Izquierda , Adulto , Arritmias Cardíacas/mortalidad , Arritmias Cardíacas/fisiopatología , Arritmias Cardíacas/terapia , Cardiomiopatía Dilatada/diagnóstico por imagen , Cardiomiopatía Dilatada/mortalidad , Cardiomiopatía Dilatada/terapia , Causas de Muerte , Muerte Súbita Cardíaca/epidemiología , Progresión de la Enfermedad , Diagnóstico Precoz , Ecocardiografía Doppler , Femenino , Trasplante de Corazón , Humanos , Incidencia , Italia/epidemiología , Masculino , Persona de Mediana Edad , Pronóstico , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de TiempoRESUMEN
AIMS: The study aimed at evaluating the reliability and reproducibility of various noninvasive echocardiographic techniques for the estimation of the main hemodynamic parameters in clinical practice. METHODS: A total of 84 patients with a generic indication of right heart catheterization (RHC) executed a transthoracic echocardiography shortly before or after the RHC. All the parameters necessary for a noninvasive hemodynamic evaluation of right atrial pressure, pulmonary artery pressure (PAP), pulmonary capillary wedge pressure, pulmonary vascular resistance and cardiac output were acquired and the agreement with the invasive measures was evaluated by a Bland-Altman analysis. RESULTS: Noninvasive evaluation of right atrial pressure showed a moderate and low correlation with RHC using inferior vena cava parameters (râ=â0.517) and tricuspid E/E' ratio (sensitivity 0.23, specificity 0.72), respectively. PAPs estimation from the tricuspid regurgitation peak velocity had a good correlation (râ=â0.836) and feasibility (82.1%), as well as PAPm from tricuspid regurgitation mean gradient (râ=â0.78, applicability 72.6%) and from pulmonary acceleration time (sensitivity 0.85, specificity 0.5, applicability 92.9%). Pulmonary capillary wedge pressure multiparametric evaluation, as suggested by the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging recommendations, showed a good correlation (sensitivity 0.96, specificity 0.59). The noninvasive evaluation of pulmonary vascular resistance and cardiac output did not prove to be clinically accurate. CONCLUSION: Various hemodynamic parameters can be adequately estimated with noninvasive methods. In particular, a multiparametric approach for the evaluation of left ventricle filling pressures is advisable and the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging recommendations are reliable even in a heterogeneous population with a significant quota of precapillary pulmonary hypertension.
Asunto(s)
Función Atrial , Cateterismo Cardíaco , Enfermedades Cardiovasculares/diagnóstico por imagen , Ecocardiografía Doppler , Hemodinámica , Función Ventricular , Anciano , Enfermedades Cardiovasculares/fisiopatología , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Valor Predictivo de las Pruebas , Pronóstico , Reproducibilidad de los ResultadosAsunto(s)
Cardiomiopatía Dilatada/fisiopatología , Atrios Cardíacos/fisiopatología , Anciano , Cardiomiopatía Dilatada/mortalidad , Cardiomiopatía Dilatada/cirugía , Ecocardiografía Doppler , Femenino , Trasplante de Corazón , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Remodelación VentricularAsunto(s)
Cateterismo Cardíaco/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Insuficiencia de la Válvula Mitral/terapia , Prolapso de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Masculino , Persona de Mediana Edad , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/fisiopatología , Prolapso de la Válvula Mitral/diagnóstico por imagen , Prolapso de la Válvula Mitral/fisiopatología , Diseño de Prótesis , Recuperación de la Función , Resultado del TratamientoRESUMEN
Aims: Despite continuous efforts in improving the selection process, the rate of non-responders to cardiac resynchronization therapy (CRT) remains high. Recent studies on intraventricular blood flow suggested that the alignment of hemodynamic forces (HDFs) may be a reproducible biomarker of mechanical dyssynchrony. We aimed to explore the relationship between pacing-induced realignment of HDFs and positive response to CRT. Methods and results: We retrospectively analyzed 38 patients from the CRT database of our institution fulfilling the inclusion criteria for HDFs-related echocardiographic assessment early pre and post CRT implantation, with available mid-term follow-up (≥ 6 months) evaluation. Standard echocardiographic and deformation parameters early pre and post CRT implantation were integrated with the measurement of HFDs through novel methods based on speckle-tracking analysis. At midterm follow-up 71% of patients were classified as responders (reduction of Left Ventricular Systolic Volume Indexed ≥ 15%). Patients did not display significant changes between close evaluations pre and post-implant in terms of ejection fraction and strain metrics. A significant reduction of the ratio between the amplitudes of transversal and longitudinal force components was found. The variation of this ratio strongly correlates (R2 =0.60) with Left Ventricular (LV) end-systolic volume variation at mid-term follow up. Conclusion: Pacing-induced realignment of HDFs is associated with CRT efficacy at follow up. These preliminary results claim for dedicated prospective clinical studies testing the potential impact of HDFs study for patient selection and pacing optimization in CRT.
RESUMEN
AIMS: Arrhythmic risk stratification is a challenging issue in patients with dilated cardiomyopathy (DCM), particularly when left ventricular ejection fraction (LVEF) is more than 35%. We studied the prevalence and predictors of sudden cardiac death or malignant ventricular arrhythmias (SCD/MVAs) in DCM patients categorized at low arrhythmic risk because of intermediate left ventricular dysfunction under optimal medical treatment (OMT). METHODS: DCM patients considered at low arrhythmic risk (LVEF >35% and New York Heart Association class I-III after 6â±â3 months of OMT) were analysed. An arrhythmogenic profile was defined as the presence of at least one among a history of syncope, nonsustained ventricular tachycardia, at least 1000 premature ventricular contractions/24âh, at least 50 ventricular couplets/24âh at Holter ECG monitoring. SCD/MVAs was considered as the study end-point. RESULTS: During a median follow-up of 152 months (interquartile range 100-234), 30 out of 360 (8.3%) patients at low arrhythmic risk (LVEF 47â±â7%) experienced the study end-point [14 (3.9%) SCD and 16 (4.4%) MVA]. Compared with survivors, patients who experienced SCD/MVAs had more frequently an arrhythmogenic profile and a larger left atrium. Their LVEF at the last available evaluation before the arrhythmic event was 36â±â12%. At multivariable analysis, left atrial end-systolic area [hazard ratio 1.107; 95% confidence interval (95% CI) 1.039-1.179, Pâ=â0.002 for 1âmm increase] and arrhythmogenic profile (hazard ratio 3.667; 95% CI 1.762-7.632, Pâ=â0.001) emerged as predictors of SCD/MVAs during follow-up. CONCLUSION: A consistent quota of DCM patients with intermediate left ventricular dysfunction receiving OMT experienced SCD/MVA during follow-up. Left atrial dilatation and arrhythmogenic pattern were associated with a higher risk of SCD/MVA.
Asunto(s)
Arritmias Cardíacas/epidemiología , Cardiomiopatía Dilatada/epidemiología , Muerte Súbita Cardíaca/epidemiología , Volumen Sistólico , Disfunción Ventricular Izquierda/epidemiología , Función Ventricular Izquierda , Adulto , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/mortalidad , Cardiomiopatía Dilatada/diagnóstico , Cardiomiopatía Dilatada/tratamiento farmacológico , Cardiomiopatía Dilatada/mortalidad , Fármacos Cardiovasculares/uso terapéutico , Femenino , Humanos , Incidencia , Italia/epidemiología , Masculino , Persona de Mediana Edad , Prevalencia , Pronóstico , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Volumen Sistólico/efectos de los fármacos , Factores de Tiempo , Disfunción Ventricular Izquierda/diagnóstico , Disfunción Ventricular Izquierda/tratamiento farmacológico , Disfunción Ventricular Izquierda/mortalidad , Función Ventricular Izquierda/efectos de los fármacosRESUMEN
INTRODUCTION: Dilated cardiomyopathy (DCM) is generally thought as a final common pathway of several conditions leading to the same clinical phenotype. Multiple imaging modalities play a fundamental role in recognizing the underlying pathological substrate in DCM. Areas covered: Echocardiography represents the first reliable and easily accessible diagnostic tool, allowing the identification of associated cardiac abnormalities, such as valve disease and highlighting features associated with an adverse prognosis. Recent advances in technology such as strain analysis and 3D-echocardiography have improved the diagnostic and prognostic capabilities of this technique. Cardiac magnetic resonance (CMR) is considered the gold standard for an accurate and reproducible assessment of ventricular volumes and ejection fraction. In addition, CMR allows us to perform tissue characterization that, through new sophisticated sequences, could be obtained even without gadolinium. Nuclear images could be useful to identify specific causes of left ventricular dysfunction, such as cardiac sarcoidosis and amyloidosis. Finally, endomyocardial biopsy is generally performed if acute myocarditis is suspected in high-risk patients. Expert commentary: Strengths and limitations are different for every method, but multiparametric evaluation of patients and family members could progressively improve current understanding of the disease. This is fundamental to specifically target therapy, allowing us to improve patients' prognosis.